Required fields

1. Request type

To change a role or add on a new role, you must complete all training requirements specific to the role(s), unless training was completed within the last 6 months.

New provider Role change Roll add-on

2. Requester information

3. Person receiving access

Yes No

The primary contact will need to submit a care manager form for the individual, if they have not already done so.

4. Roles

Practice Manager Supervisor Billing Manager Attester Trainer Program Coordinator Admin Assigner

5. Approval

6. Attachments

7. Submittal

I certify that all of the representations made above are accurate and truthful. I represent that in working with Humana At Home Care Management Network, my company, employees, subcontractors and I agree to abide by the Code of Ethics of our parent profession(s). I affirm that I agree to work in a collaborative team with the other professionals and Humana At Home staff. Applicant has been vetted for any issues that could hinder this potential practice personnel’s working relationship with Humana including any pending investigations, suspensions, warnings, court hearings, open tickets, disciplines on licenses, registrations and or certifications.